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Tanglewood Assisted Living
At Tanglewood Assisted Living, we practice the five foot rule with memory loss patients. If you wish to be understood by a memory loss patient, you should be within five feet of that person when you speak to them. Most memory loss patients simply cannot process words that are shouted at them from across the room. In order to communicate effectively you should get close, make eye contact and begin by using the person’s first name.
If the patient is sitting down, you should not stand over them and talk down to them. When you stand up, you assume a dominate posture which makes people feel uncomfortable. Instead, kneel down so you are at the same eye level as the patient and you will immediately put them at ease.
Touch is important to memory loss patients. While you’re speaking, hold their hand or put your hand on their arm or shoulder. Be generous with hugs and handshakes.
At Tanglewood, the staff is trained repeatedly to maintain a calm and pleasant tone of voice. Memory loss patients have not lost their ability to appreciate tone of voice and if you become upset you will only make a bad situation worse. Some patients will be depressed or mad at the world. With these you should commiserate. Offer compassion, sympathy and condolences. Other patients may be mad at you. They may accuse you of all sorts of atrocities. With these folks you should simply apologize and say you’ll try to do better. You should never get mad. Always remain calm and pleasant.
If you do feel yourself becoming upset, walk away. Make sure the patient is safe and walk away. Come back in ten minutes and the patient’s attitude will have changed completely.
Ask only simple questions of a memory loss patient - questions which require a yes or no answer. Don’t ask “would you like lemonade or ice tea?” Even such mildly complex questions generate confusion. Ask only yes or no questions.
The best chance of having a coherent conversation with a middle or late stage memory loss patient is to talk about events that happened long ago. Such very old memories usually remain intact and the memory loss patient will feel comfortable talking about them. If possible, bring photographs from the patient’s younger days and talk about the people and places in the pictures.
Finally, musical memories also remain intact. A patient will remember and enjoy the lyrics and melodies of music they’ve heard throughout their lives and especially music they heard as a child. They will usually enjoy and sing along with hymns and pop music songs they heard in their youth.
Unfortunately, almost all memory loss patients will become incontinent. At first they will have an occasional accident but eventually they will forget when and how to use the bathroom and will need to wear an undergarment all the time. While nothing can prevent this from happening, there are some techniques which can delay incontinence and cut down on the number of accidents.
Prompting: Accidents often occur because the memory loss patient simply waited too long before heading for the bathroom. If a caregiver will prompt the patient every two to three hours, by asking if they need to use the bathroom, the number of accidents can be reduced significantly. If the memory loss patient continually says they don’t need to use the bathroom, the caregiver should respond with “let’s give it a try” and help the patient to the bathroom. By the time you get to the bathroom, the memory loss patient may suddenly realize they have to go. An old trick which may help is to sit the patient on the toilet and run water.
Bedside Commodes: Many accident happen at night. Often a sleepy resident will have trouble getting to the bathroom in time. Putting a portable commode next to the bed and keeping a night light in the room will help this situation.
Washable Protective Pads: An incontinent patient can damage or destroy furniture, mattresses and carpeting. A caregiver may have to remove and wash bed linen every morning. Even the best undergarments are subject to leaks.
If you have a loved one in the house who suffers with incontinence, you should cover your furniture with washable protective pads, often called “chuck” pads. Chuck pads should be used to cover furniture and mattresses. Even mattresses with waterproof mattress pads should also have an extra large chuck pad underneath. These pads are now available in a variety of colors to match the furniture.
Undergarments: Some undergarments pull up and down like underwear and are useful in the early stages of incontinence when the patient still uses the bathroom by themselves and the undergarment is mainly to protect against accidents. To change this type of undergarment however, the caregiver must remove the patients shoes and pants to put on a new undergarment.
This inconvenience can be avoided by using briefs which are secured on the sides with elastic bands and buttons. These can be changed without removing the patient’s pants.
Memory loss in the elderly, whether brought on by Alzheimer’s disease or some other cause, is a progressive condition, becoming worse over time. At some point in the progression of this condition an elderly patient will lose the ability to make rational decisions and someone else, usually an adult child, will have to take over responsibility for making medical and financial decisions on behalf of the memory loss patient. For this change to take place legally, quickly and inexpensively, two important documents must be signed by the elderly patient while they are still competent to make legal decisions.
Medical Durable Power of Attorney
A Medical Durable Power of Attorney (MDPA) is a legal document appointing someone else to speak for a patient regarding medical decisions, in the event the patient cannot speak for themselves. The document specifically names an individual, plus one or two alternates, to take charge of medical care. The document also allows a patient to specify certain types of treatment they do or do not want in the event the patient cannot speak for themselves and will not recover from their illness. Ideally, this document should be signed long before someone develops memory loss.
If an elderly patient is diagnosed with memory loss and does not have a MDPA in place, the patient may still have time to sign a MDPA. Most elderly patients in the very early stages of memory loss, are still quite independent and rational and would still be considered legally competent to sign legal documents. This fact affords the memory loss patient an opportunity to execute and sign a MDPA even after being diagnosed. Once a memory loss diagnosis is made, the elderly patient and their family need to move quickly to have a MDPA executed, before the elderly patient’s competency to sign legal docments become questionable. Memory loss can progress quite rapidly in some patients and dramatic changes in abilities can occur almost overnight.
The family of a patient with memory loss will be called upon to make difficult choices regarding medical care. One such choice occurs frequently with late-stage memory loss patients and provides a good example of the importance of an MDPA. Near the end of life, many memory loss patients stop eating. A patient may be hand-fed for a time but eventually the patient stops swallowing and any further attempts at hand-feeding will cause aspiration or choking. At this point the family must decide whether to connect their parent to a feeding tube or allow their loved one to pass away. With an MDPA in place, the family will not have to guess how their parent felt about such a difficult decision. The MDPA will state specifically whether the patient does or does not want such life-prolonging medical care.
The MDPA accomplishes many objectives. It makes the transition of responsibility for medical decisions smooth and inexpensive, avoiding the possibility of costly and time-consuming court hearings. It allows the elderly parent to set forth in detail the type of medical treatment they do or do not wish to receive in the event they are terminally ill and cannot speak for themselves. It relieves the adult children of the burden and uncertainty of trying to guess how the parent felt about life-prolonging medical treatment. It allows the patient advocate to execute a Do-Not-Resuscitate Order to make certain the facility caring for their parent follows their parent’s wishes regarding life-prolonging medical treatment.
General Durable Power of Attorney
Similar to a Medical Durable Power of Attorney, a General Durable Power of Attorney (GDPA) appoints someone to act on behalf of the memory loss patient for financial and property decisions. (If the memory loss patient has a trust, the language of the trust may have the same effect as the GDPA, giving authority to a successor trustee to handle financial affairs when the memory loss patient can no longer handle such matters.) Without a GDPA (or the equivalent language in a trust,) a court hearing will be required to appoint and empower a conservator who will handle financial and property affairs for the memory loss patient. Such court hearings can be expensive.
Both the Medical Durable Power of Attorney and the General Durable Power of Attorney are critical legal documents. They give effect to the wishes of the people involved and they avoid the expense and uncertainty of probate court oversight.
Such powerful impulses often drive patients to leave their own home or an assisted living facility and wander away outside. Sometimes patients will wander outside even in the worst weather. Sadly, wandering is a common cause of injury and death for memory loss patients.
DOOR ALARMS: Door alarms are essential for any home where a memory loss patient resides. Wireless versions are available at many hardware stores and are easy to install. Magnetic transmitters are attached next to each exit door and generate an electrical signal whenever the door is opened. The signal then triggers an alarm. During the day the device can be set to emit a one-time alarm, something like a doorbell. At night the setting can be changed so the device emits a noisy, continuous alarm, something akin to a police siren. The alarm will continue to sound until a until a switch on the side of the device is reset. The continuous alarm ensures that a sleeping caregiver will wake up if their loved one is trying to walk out at night. (The alarm has the added benefit of deterring anyone attempting to force entry into your house at night.)
Although more elaborate and expensive alarm systems are available, such as ones that sound only when the memory loss patient approaches an exit door, a simple wireless system is probably sufficient. Remember, these alarms don’t work unless the door is closed each time between uses.
WINDOW PROTECTION: Memory loss patients can be very determined and will occasionally climb out a window. Windows can be fitted with stop guards which only allow the window to open a few inches. Some windows have stop guards built-in and if not, after-market stop guards can be purchased inexpensively at your local hardware store. Check with your fire department before installing any device that limits the opening of a window which may be considered a fire exit. Window alarms, which function like door alarms, are also available at many hardware and home supply stores.
SUPERVISED WALKS: For memory loss patients who remain physically fit and active, a long walk outside with a caregiver can reduce the patient’s desire to leave the house. In addition to reducing the desire to wander, the fresh air and the exercise can also help with the patient’s sleep habits and overall attitude. Usually, longer walks produce better results. The patient returns to the house tired, more content and less agitated. If the patient is willing, you should take walks in all seasons. Walks help the caregiver as well and provide memories of quality time spent with a loved one.
IDENTIFICATION WRIST BANDS: Memory loss patients can be fitted with a bracelet which serve the same purpose as a medical alert bracelet. The bracelet identifies the person and their condition and includes phone numbers to call if anyone encounters the memory loss patient on the street. This type of identification is a good idea provided the memory loss patient will wear the bracelet.
SEARCHING: If a memory loss patient does wander off, call the police immediately. Many police departments have tracking dogs trained to follow a scent. Call local television stations to broadcast pictures and information about your lost loved one. Immediately have someone visit or call everyone in your neighborhood. Often a memory loss patient will end up on the porch or in the garage of a nearby house. Have as many people as possible begin searching in cars and on foot or bicycle.
Finding a Safe Long-Term Care Facility
Licensing: Is the facility licensed and inspected by the state? If the facility is licensed, the state will inspect on a regular basis to make sure the facility meets state standards regarding both the safety of the facility and the quality of care. If the facility is licensed, the facility should be willing to provide you with the name and phone number of the state inspector who oversees the facility. You should feel free to make inquires with the inspector about the facility you are considering.
Staff Training and Staff-to-Patient Ratio: Facilities should also be willing to provide you with information on staff training. You should be certain the staff is trained in CPR and first aid. If the facility claims to specialize in memory loss, ask what specialized training is provided. Ask about the staff-to-patient ratio; that is the number of direct care workers on duty compared to the number of residents. For example, if two direct care workers are on duty at a twelve (12) bed facility, the staff to patient ratio is one to six (1:6). If two workers are on duty at a twenty (20) bed facility, the ratio is one to ten (1:10). You should keep in minds the needs of the residents when deciding what staff to patient ratio is adequate. Also, ask which employees are included when determining the staff-to-patient ratio. Many facilities count all employees in determining this ratio. They count cooks, maintenance employees, secretaries, managers and administrators, most of whom have little or nothing to do with providing direct care to residents. Including all these employees makes the staff-to-patient ratio sound impressive but it does not accurately reflect how many direct care staff are available to attend to the needs of the residents. You should ask for a staff-to-patient ratio which only includes direct care staff.
Fall Prevention: Probably the most common injuries at assisted living facilities are injuries from falls. While no facility can guarantee falls won’t occur, they should tell you what steps are taken to prevent falls. Are there stairs in the facility (always a bad idea). Are there ramps at every exit? Are there handrails and grab bars throughout the facility. Does the facility use monitors to alert staff when a resident is trying to get out of bed or out of a wheelchair. Try to determine the staff response time if a fall does occur. In larger facilities, response time can often be lengthy.
Wandering: If a resident has memory loss, you need to know how the facility will prevent wandering, an industry term for residents who walk out the door. Most facilities rely on door alarms however, a door alarm is of no value unless the staff responds promptly to every alarm. You should spend some time at the facility to see how quickly and religiously the staff responds when a door alarm is activated.
Fire Prevention: Fires at elder care facilities happen all too frequently. In Michigan, all new facilities with more than 6 beds should be protected by a sprinkler system. Unfortunately, some older facilities are exempt from this requirement and are allowed to operate without a sprinkler systems. If there isn’t a sprinkler system, you should ask yourself, realistically, how quickly will the staff be able to get the residents out. Keep in mind, many residents can’t walk and some can’t get out of bed. Ask if you can sit in on a fire drill.
Power Outages: Finally, power outages are a fact of life. Some outages last several days. If power goes out in the winter, the facility will be without heat. Check to be sure the facility maintains a standby back-up generator, one which will power the entire facility automatically when a power outage occurs.